Received Ceph Analysis from Ortho; Now Need Help on What to Say to Surgeon

[Kadath]

Hello, first time poster.

My insurer is covering my jaw surgery for functional reasons (sleep apnea, recessed maxilla that makes my air pipes the size of a pencil, etc.), but my orthodontist and surgeon are open to creating an aesthetic result for me.

A little background on me: I wore headgear when I was young (12-14) and it recessed my maxilla and pulled my upper jaw back. Unfortunately, I didn't know anything about proper bone development at the time because it was so long ago. I'm 35 now and realize how debilitating that terrible headgear and my past orthodontist were inmy bone development.

I recently got this ceph analysis back from a current orthodontist who I consulted with. Originally I went directly to my insurer's jaw surgeon, but he said he would need to work with an ortho first, so that's where she got involved. Great thing about her is that she actually does understand how bad my last ortho messed up and is very much in my corner when it comes to me having jaw surgery. I've attached my ceph analysis (https://imgur.com/a/wUaFSVx) and I wanted to ask your opinions on the following:

1. My ortho recommended a lefort 1 and bsso to move my jaws forward. How far should I ask that my jaws be moved forward?
2. Is lefort 1 the right answer or should I ask for a lefort 2? I have a good amount of hollowness under my eyes.
3. The ortho wants to use invisalign before the surgery to bring my underbite even further back because my "teeth flare outwards", she says by doing this the jaw surgeon can then align both jaws more effectively and bring them further out.
4. My ortho said the surgeon should also be able to widen my upper palate so that my tongue can rest more properly on the roof of my mouth. Can this be done and by how much should it be to create a good space for my tongue?
5. The ortho said it's an unstable surgery to widen the lower palate though so she said the jaw surgeon shouldnt do that. Is that true?
6. I'd like to reduce my "long face." Can this be done through the procedures i mentioned? what can i ask for to help shorten my face, especially in the mid-face area?

Thanks for any feedback, like I said I'm looking to get the most aesthetic result possible.

[Lefortitude]

1. My ortho recommended a lefort 1 and bsso to move my jaws forward. How far should I ask that my jaws be moved forward?
2. Is lefort 1 the right answer or should I ask for a lefort 2? I have a good amount of hollowness under my eyes.
3. The ortho wants to use invisalign before the surgery to bring my underbite even further back because my "teeth flare outwards", she says by doing this the jaw surgeon can then align both jaws more effectively and bring them further out.
4. My ortho said the surgeon should also be able to widen my upper palate so that my tongue can rest more properly on the roof of my mouth. Can this be done and by how much should it be to create a good space for my tongue?
5. The ortho said it's an unstable surgery to widen the lower palate though so she said the jaw surgeon shouldnt do that. Is that true?
6. I'd like to reduce my "long face." Can this be done through the procedures i mentioned? what can i ask for to help shorten my face, especially in the mid-face area?

1) you should probably let your surgeon and orthodontist decide what movements they want to do for you. Jaw surgery is a complex set of movements along multiple dimensions that have to come out basically perfectly.  For me, that ceph tracing dosnt provide enough information to draw up a plan. not that I would be qualified anyways.
2)  LF2 will not be covered under your insurance (most likely) and will also likely be refused by your surgeon. Also the LF2 fracture moves the nose (pyriform aperture) and not the inferior orbital rim (which would address the hollowness you speak of)
3) Invisilign CAN be used to prep for surgery but braces are usually more accurate.  I dont see an underbite in your ceph, so im not sure how to comment on this.
4) You only have one palate (upper).  This can be done with a segmented lefort 1.  Its a pretty common procedure with a good success rate. However, it is not usually done exclusively to create tongue space, but to make sure the bite fits together correctly.  The bite is paramount.
5) lower palate does not exist.  its your lower arch.  Yes, your ortho was correct, nobody with any level of competence would widen your lower jaw with jaw surgery.
6) The mid face length can be reduced through jaw rotation in the counter clockwise direction.  However your bite plane looks pretty flat so theres probably only a few degrees of rotation you can get. Id talk to your surgeon about this.

Your airway is non existent and this surgery will be a major improvement to your QOL. Best of luck.

[Post bimax]

Does CCW-r actually make the midface appear shorter?

[kavan]

What you got back was a ceph TRACING. The analysis is the part where they list a bunch of numbers, measures and angles that tell them how much you deviate from the norm. From there they start planning out what kind of displacements, angle changes they need to make.  If you want to see what their PLANS are for the profile changes, you need to ask for a displacement proposal which is a diagram of the proposed changes shown as a contour diagram next to the contour diagram of your present profile. It also would list all the displacements that go with it.

1: A L1 and BSSO are used to move jaws forward. It's not something where you are in capacity to ask them how far to move. That's something they determine by actually coming up with a plan.

2: LI and BSSO is standard for double jaw advancement. Not something where you can ask for a Lefort 2. Jaw surgery is not meant to address the under eye area.

3: An underbite is when your lower teeth are ahead of the upper teeth. Although I don't really see an underbite, if the lower teeth need to be pushed back in preparation of the surgery, then that's what they need to do.

4: Yes, they can widen the upper palate. It's part of the maxilla bone.

5: The lower 'palate'  can't be made wider. It's not a 'palate'.

6: Your ceph does not really show a 'long face'.

What you need to ask for is a displacement proposal that shows the profile changes via a contour diagram super imposed over a PRESENT contour diagram that can be drawn from your ceph X ray; some VISUAL where you can see/get some idea of the changes they plan to make.

[Kadath]

I really appreciate all of your thoughts, especially kavan and lefortitude. i'm especially looking forward to breathing much better lol - even the orthodontist was shocked at my airway or lack thereof.

I'll definitely follow up and ask about the ceph analysis and plan, kevan.

kevan: as you said you don't really see an "underbite", i'm wondering if this is actually necessary to get the jaw surgery or is this something that my ortho is just saying?
lefortitude: can my lower jaw be widened with invisalign?

[kavan]

I really appreciate all of your thoughts, especially kavan and lefortitude. i'm especially looking forward to breathing much better lol - even the orthodontist was shocked at my airway or lack thereof.

I'll definitely follow up and ask about the ceph analysis and plan, kevan.

kevan: as you said you don't really see an "underbite", i'm wondering if this is actually necessary to get the jaw surgery or is this something that my ortho is just saying?
lefortitude: can my lower jaw be widened with invisalign?

The ortho SHOULD be working WITH the surgeon to get your teeth into a position to have surgery. They probably mean they want to push your lower teeth back more. Maybe the term 'underbite' was used loosely. The braces don't widen the lower jaw. The lower jaw will look wider when it's brought forward.

[Lefortitude]

The ortho SHOULD be working WITH the surgeon to get your teeth into a position to have surgery. They probably mean they want to push your lower teeth back more. Maybe the term 'underbite' was used loosely. The braces don't widen the lower jaw. The lower jaw will look wider when it's brought forward.

This is correct. The lower jaw can not be physically cut and widened. the teeth can be tilted to some degree to widen the lower arch.

[Post bimax]

Lefortitude-

Are you saying his midface can actually be shortened via CCW-r or that a CCW movement would mitigate implicit midface lengthening caused by a straight MMA?

[Lefortitude]

Lefortitude-

Are you saying his midface can actually be shortened via CCW-r or that a CCW movement would mitigate implicit midface lengthening caused by a straight MMA?

impaction would shorten the midface. anterior impaction would shorten the midface and get ccw rotation.

[Post bimax]

impaction would shorten the midface. anterior impaction would shorten the midface and get ccw rotation.

Oh, yeah. I was only thinking of posterior downgrafts.

[Kadath]

lefortitude: what is anterior impaction? that sounds like something i'd want to bring up with my surgeon.

[Post bimax]

lefortitude: what is anterior impaction? that sounds like something i'd want to bring up with my surgeon.

It means 'impacting' the front of your upper jaw.  The surgeon will basically take a wedge out of your maxilla to shorten it in the front.  This sounds nice, but it will also reduce your tooth show so it's usually not done unless you have a gummy smile.

[kavan]

Lefortitude-

Are you saying his midface can actually be shortened via CCW-r or that a CCW movement would mitigate implicit midface lengthening caused by a straight MMA?

The midface refers to the division of equal '1/3rds'. It refers to the middle '1/3rd' of the face measured between the glabella and base of the nose. Upper '1/3rd' is from part of forehead and glabella. Lower '1/3rd' is from base of nose to bottom of chin.

This division is taken from Leonardo's and Durer's basic guidelines of how a normal face could be divided for basic drawing. The artists themselves did not mean these ratios to be an aesthetic cannon defining any 'ideal'. But somehow surgeons (with no background in art, art history aesthetic theory etc.) took it to be one and since divide the face that way.

This 'middle 1/3rd' (or midface) can not be physically shortened or made longer because it applies to a span of face where the NOSE is smack in the middle (distance between 'root of nose and base of nose) where the whole span of the face (from about ear to ear) can't have an entire bone segment cut though that span make it shorter. If the excess length to the face is found between glabella (or 'root' of nose) and base of nose, that area is not vertically shortened.

The bone structure of the face that can be made shorter or longer is the area of lower '1/3rd', in particular the area between the base of the nose and the bottom of the teeth. Sometimes, it's THAT area that can give rise to the PERCEPTION of a long midface. For example someone who's face is long between the glabella/root of nose and the bottom of chin where the excess length is attributable to excess bone growth between the base of the nose and the bottom of the teeth can have that area made shorter. In that case CCW-r via removing a wedge segment from the anterior maxilla will help that. (eg someone with gummy smile and very steep OP). The person having that situation might perceive themselves as having long 'midface' and perceive the midface 'shorter' when the face is put into balance by altering an area that is in the 'territory' of the 'lower 1/3rd' but the middle 1/3rd basically remains the same vertical distance.

CCW in maxfax is done to decrease the angle of inclination you have to move along to get a selected horizontal displacement of the maxilla while minimizing any unwanted vertical displacement that might go along with that which could be unfavorable changes to the base of the nose which can occur to the lower 1/3rd of face with reference to how the face is divided.  Anytime one moves something along an incline, (for example a 'steep' OP) there is both a horizontal and vertical displacement. So to get a selected horizontal displacement of 'x' and mitigate an unwanted displacement of 'y', the angle of inclination moved along needs to be decreased. So, CCW whether it's anterior impaction or posterior downgraft is basically to have more control over unwanted vertical displacements that would arise by moving something 'forward' along in incline. The 'flatter' the plane is one moves along, the less vertical component there will be in getting the selected horizontal displacement.

I'm probably boring and/or confusing a lot of people reading this. But I know it's in your capacity to understand.

[Post bimax]

Kavan-

Yes that makes sense. So a large straight MMA advancement with a steeper OP amounts to a ‘forwards and downwards’ movement because the jaws are advancing along the OP, potentially increasing perceived midface length. Mostly because 1. The philtrum is closer to the observer and 2. The nasal tip may tilt upwards, increasing the perceived length from the nasal base to the chin (and nasal base to upper lip vermillion).

It’s also effectively a CW movement if the S-N is oriented CW.

Kadath-

Kavan may confirm whether the above is accurate which will give you some things to consider. I’m curious though- what makes you think your face is long? I suspect it is the length of your philtrum. Your surgeon is going to propose movements based on xrays and clinical photos, and tooth show is usually a big factor. He’s not going to impact the anterior of your maxilla if your tooth show is good because poor tooth show is very aging. You would need to get a lip lift in conjunction with your bimax (or more likely several months prior). Not all surgeons are open to such suggestions though.

Further, your OP does not look particularly steep (eyeballing) so a CCW rotation is not indicated. I doubt he would impact the entire upper jaw. Still ask the surgeon about all of these things though and gauge his responses. You will only regret the questions you didn’t ask.

[kavan]

Kavan-

Yes that makes sense. So a large straight MMA advancement with a steeper OP amounts to a ‘forwards and downwards’ movement because the jaws are advancing along the OP, potentially increasing perceived midface length. Mostly because 1. The philtrum is closer to the observer and 2. The nasal tip may tilt upwards, increasing the perceived length from the nasal base to the chin (and nasal base to upper lip vermillion).

It’s also effectively a CW movement if the S-N is oriented CW.

Kadath-

Kavan may confirm whether the above is accurate which will give you some things to consider. I’m curious though- what makes you think your face is long? I suspect it is the length of your philtrum. Your surgeon is going to propose movements based on xrays and clinical photos, and tooth show is usually a big factor. He’s not going to impact the anterior of your maxilla if your tooth show is good because poor tooth show is very aging. You would need to get a lip lift in conjunction with your bimax (or more likely several months prior). Not all surgeons are open to such suggestions though.

Further, your OP does not look particularly steep (eyeballing) so a CCW rotation is not indicated. I doubt he would impact the entire upper jaw. Still ask the surgeon about all of these things though and gauge his responses. You will only regret the questions you didn’t ask.

Well the word; 'forward' is tricky. When we go 'forward' along an incline there is both a pure horizontal and pure vertical element involved with the displacement. So when a steep OP is advanced, we go horizontally forward AND vertically downward. Any unwanted vertical displacement is seen at the nose base and/or below. I guess you could say that it's seen at the 'border' of the midface and the lower face relative to the division of 1/3rds which might kick up perception of changes to midface.

Anyway, the original poster does not have a long midface. So, there's not much point in discussing ways to reduce it.